Health provider identified barriers and facilitators to weight management for individuals with spinal cord injury

Patient Perceptions and Clinical Assessments of Cardiometabolic Disease After Subacute Spinal Cord Injury

OBJECTIVES

To investigate the effectiveness of health care team communication regarding cardiometabolic disease (CMD) risk factors with patients with subacute spinal cord injury (SCI).

DESIGN

Multi-site prospective cross-sectional study.

SETTING

Five National Institute on Disability, Independent Living, and Rehabilitation Research Model SCI Rehabilitation Centers.

PARTICIPANTS

Ninety-six patients with subacute SCI, aged 18-70 years, with SCI (neurologic levels of injury C2-L2, American Spinal Injury Association Impairment Scale grades A-D), and enrolled within 2 months of initial rehabilitation discharge (N=96).

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Objective risk factors of CMD (body mass index, fasting glucose, insulin, high-density lipoprotein cholesterol, triglyceride levels, and resting blood pressure). Patient reported recall of these present risk factors being shared with them by their health care team. Medications prescribed to patients to address these present risk factors were checked against guideline- assessed risk factors.

RESULTS

Objective evidence of 197 CMD risk factors was identified, with patients recalling less than 12% of these (P<.0001) being shared with them by their health care team. Thirty-one individuals (32%) met criteria for a diagnosis of CMD, with only 1 of these patients (3.2%) recalling that this was shared by their health care team (P<.0001). Pharmacologic management was prescribed to address these risk factors only 7.2% of the time.

CONCLUSIONS

Despite high prevalence of CMD risk factors after acute SCI, patients routinely do not recall being told of their present risk factors. Multifaceted education and professionals' engagement efforts are needed to optimize treatment for these individuals.

Physical and emotional consequences of excess weight as experienced by individuals with spinal cord injuries

CONTEXT/OBJECTIVE

Excess weight has the potential to carry a substantial physical and emotional burden. A better understanding of perceived consequences of excess weight may facilitate the development of patient-centered programs and interventions to promote weight management efforts in persons with spinal cord injury (SCI). The study objective was to describe consequences of excess weight from the personal perspectives of individuals with SCI.

DESIGN

Descriptive qualitative design using in-depth semi-structured interviews and thematic analysis.

SETTING

Veterans Health Administration (VHA) SCI System of Care.

PARTICIPANTS

Individuals with SCI (n-33).

OUTCOME MEASURES

Key themes from thematic analysis.

RESULTS

Participants were male (61%), ranged from 29 to 84 years of age, and about half had tetraplegia (55%). Five themes were identified that demonstrate negative consequences of excess weight experienced by individuals with SCI, including: (1) physical health conditions (including chronic conditions and SCI secondary conditions), (2) physical symptoms (such as pain, discomfort, and fatigue), (3) movement challenges, (4) appearance-related concerns, and (5) emotional impacts.

CONCLUSIONS

Carrying excess weight is concerning to individuals with SCI and in terms of consequences such onset or exacerbation of chronic conditions, SCI secondary conditions, physical symptoms, e.g. pain, movement impairment (including hampered mobility, difficult transfers and self-care), image/appearance concerns (e.g. body image, clothing misfit), and negative emotions (e.g. unhappy, sad, depressed). Our findings may inform SCI healthcare providers about the consequences of excess weight as experienced by individuals with SCI, highlighting what matters most to persons with SCI and guiding a patient-centered approach to weight management in this population.

Why may patients with spinal cord injury be overlooked for obesity screening in the Veterans Health Administration? Qualitative research of the perspectives of patients and healthcare providers

PURPOSE

We sought to describe factors influencing reduced rates of obesity screening for patients with spinal cord injury (SCI) in the United States Veterans Health Administration (VA) and to foster potential solutions.

MATERIALS AND METHODS

Semi-structured interviews with healthcare providers and patients with SCI who were recruited nationally from diverse VAs. We performed rapid qualitative analysis using content analysis of interview data.

RESULTS

There were 36 providers and 37 patients. We identified provider, patient, and system level barriers to obesity screening for individuals with SCI. Overarching barriers involved provider and patient perceptions that obesity screening is a low priority compared to other health conditions, and body mass index is of low utility. Other obesity screening barriers were related to measuring weight (i.e., insufficient equipment, unknown wheelchair weight, staffing shortages, measurement errors, reduced access to annual screening, insufficient time, patient preference not to be weighed) and measuring height (i.e., insufficient guidance and equipment to this population, measurement errors).

CONCLUSIONS

Barriers to obesity screenings exist for patients with SCI receiving care in VA. Healthcare provider and patient interviews suggest possible solutions, including standardizing height and weight measurement processes, ensuring equipment availability in clinics, clarifying guidelines, and offering support to providers and patients.IMPLICATIONS FOR REHABILITATIONIndividuals with spinal cord injury (SCI) have higher rates of obesity, but are often overlooked for annual obesity screening, even in clinic settings designed to care for individuals with SCI.Results may help tailor guidelines/education for healthcare and rehabilitation providers offering them guidance for improving obesity screening for individuals with SCI by standardizing weight and height measurement and documentation. To facilitate this, findings highlight the need for resources, such as ensuring clinics have necessary equipment, and increasing patient access to support and equipment.Improving the provision of obesity screening for individuals with SCI is necessary to improve health outcomes and patient satisfaction with care.

Informal Caregivers' Perceptions of Facilitators of Successful Weight Management for People With Spinal Cord Injury

IMPORTANCE

Informal caregivers have valuable insights that occupational therapists can use to prevent and manage problems that may arise in people with spinal cord injury (SCI) because of a lack of physical activity and poor nutrition.

OBJECTIVE

To assess caregiver-identified facilitators of weight management in people with SCI.

DESIGN

Descriptive qualitative design using semistructured interviews and thematic analysis.

SETTING

Regional SCI Care Model System and Veterans Health Administration.

PARTICIPANTS

Informal caregivers (n = 24) of people with SCI.

OUTCOMES AND MEASURES

Facilitators of successful weight management in care recipients with SCI.

RESULTS

Four themes were identified as weight management facilitators: healthy eating (subthemes: food content, self-control, self-management, and healthy preinjury lifestyle), exercise and therapy (subthemes: occupational and physical therapy, receiving assistance, and resources for exercise), accessibility, and leisure activity or activities of daily living, the latter described as a source of activity (because of required energy expenditure) to facilitate weight management for people with more severe injuries.

CONCLUSIONS AND RELEVANCE

These findings can inform the development of successful weight management plans by occupational therapists by incorporating feedback from informal caregivers. Because caregivers are involved in many of the facilitators identified, occupational therapists should communicate with the dyad about sourcing accessible places to increase physical activity and assessing in-person assistance and assistive technology needs to promote healthy eating and physical activity. Occupational therapists can use informal caregiver-identified facilitators of weight management to help prevent and manage problems for people with SCI secondary to limited activity and poor nutrition. What This Article Adds: Occupational therapy practitioners provide therapeutic intervention to people with SCI; this includes attention to weight management from the time of initial injury throughout their lives. This article is novel in the presentation of informal caregivers' perceptions about successful facilitators of weight management among people with SCI, which is important because caregivers are intimately involved in the daily activities of people with SCI and can be a liaison for occupational therapists and other health care providers about ways to facilitate healthy eating and physical activity.

The impact of the COVID-19 pandemic on individuals living with spinal cord injury: A qualitative study

PURPOSE/OBJECTIVE

To explore the impact of the COVID-19 pandemic as experienced and reported by individuals living with a spinal cord injury (SCI).

RESEARCH METHOD/DESIGN

Descriptive qualitative design using in-depth semistructured interviews with individuals with SCI (n = 33) followed by thematic analysis.

RESULTS

Three main themes described impacts of the COVID-19 pandemic. (a) Impact on health care use; subthemes elaborated that this was attributable to in-person health care facility restrictions or individual decisions to delay care. Individuals with SCI experienced lapses in primary and SCI-specialty care, rehabilitation/therapy services, and home care, but some made use of telehealth services. (b) Impact on weight and/or weight management lifestyle behaviors; subthemes discussed that engagement in physical activity declined because of fitness center closures, recreational activity cancellations, and safety precautions limiting community-based and outdoor activities. The pandemic disrupted participants' independence in purchasing and making preferred food selections which impacted healthy eating. Participants ate due to boredom, at nonmealtimes, and consumed unhealthy foods during the pandemic. (c) Impact on psychosocial factors; included subthemes noting reduced social interactions, social participation, and ability to pursue pastimes with family, friends, and groups they belonged to. The pandemic also triggered emotional reactions such as worry, fear, doubt, demotivation, and feelings of social isolation.

CONCLUSIONS

Our findings highlight the magnitude of consequences faced by individuals with SCI when restrictions to health care, healthy lifestyle endeavors, and social participation occurred during the COVID-19 pandemic. Findings may inform SCI health care providers on what is needed in response to future public health or natural disaster crises. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Health care provider views on the magnitude of overweight/obesity in spinal cord injury and awareness of evidence-based guidance for weight management

BACKGROUND

Literature shows that large proportions of people with a spinal cord injury (SCI) continue to experience challenges and limitations in weight management (WM) efforts in the health care setting. Despite the need, evidence-based research on effective and practical WM practices for persons with SCI is inconsistent and not widely used by health care providers (HCPs).

OBJECTIVE

The objectives were twofold: (1) to explore HCP perspectives of the extent of the problem of overweight/obesity in individuals with SCI and (2) HCPs awareness of and beliefs about availability of literature or evidence-based guidelines that discuss WM in SCI.

DESIGN

Qualitative study using semistructured interviews with HCPs and thematic analysis to identify themes.

PARTICIPANTS/SETTING

SCI HCPs (n = 25) from Veterans Health Administration and Midwest Regional SCI Care System.

INTERVENTION

Not applicable.

RESULTS

SCI HCPs (88%) emphasized the large scope of the problem of overweight and obesity in persons with SCI. HCPs noted the multiple associated negative consequences, specifically 84% highlighted the impact on chronic conditions (cardiometabolic, respiratory) and 48% discussed the impact on secondary/associated conditions (skin, bowel, bladder, musculoskeletal). HCPs noted other impacts of excess weight as greater disability in later life (28%), challenges with mobility and function (60%), self-care (24%), and equipment safety (28%). This sample of HCPs (76%) indicated being unaware of published or available information about WM efforts that work in SCI populations.

CONCLUSION

Our findings indicate that HCPs believe that overweight and obesity is a significant problem in persons with SCI but that this sample of HCPs are not aware of published work and easily accessible SCI-specific WM evidence-based guidance. This suggests the need for more education and proactive efforts to improve awareness of appropriate information within interprofessional HCPs.

Nutrition Education to Reduce Metabolic Dysfunction for Spinal Cord Injury: A Module-Based Nutrition Education Guide for Healthcare Providers and Consumers

Spinal cord injury (SCI) results in a high prevalence of neurogenic obesity and metabolic dysfunction. The increased risk for neurogenic obesity and metabolic dysfunction is mainly due to the loss of energy balance because of significantly reduced energy expenditure following SCI. Consequently, excessive energy intake (positive energy balance) leads to adipose tissue accumulation at a rapid rate, resulting in neurogenic obesity, systemic inflammation, and metabolic dysfunction. The purpose of this article is to review the existing literature on nutrition, dietary intake, and nutrition education in persons with SCI as it relates to metabolic dysfunction. The review will highlight the poor dietary intakes of persons with SCI according to authoritative guidelines and the need for nutrition education for health care professionals and consumers. Nutrition education topics are presented in a module-based format with supporting literature. The authors emphasize the role of a diet consisting of low-energy, nutrient-dense, anti-inflammatory foods consistent with the Dietary Guidelines for Americans' MyPlate to effectively achieve energy balance and reduce the risk for neurogenic obesity and metabolic dysfunction in individuals with SCI.

Development and evaluation of an educational curriculum for healthcare providers on overweight/obesity management in individuals with spinal cord injury based on diverse stakeholder engagement

BACKGROUND

Spinal cord injury (SCI) healthcare providers are aware of the harmful consequences of overweight/obesity in persons with SCI, but many are unaware of available information and lack training to guide weight management care in the SCI population.

OBJECTIVE

Describe the development and content of an educational curriculum for healthcare providers to help individuals with SCI prevent or manage overweight/obesity.

METHODS

The biopsychoecological framework guided curriculum planning, data collection, and product development. Thematic analysis of interviews conducted with individuals with SCI, informal caregivers, and SCI healthcare providers pinpointed central educational curriculum topics. SCI healthcare providers evaluated the curriculum.

RESULTS

Seven comprehensive topics were developed: 1. Scope and consequences of overweight/obesity in SCI; 2. Classifying and measuring overweight/obesity in SCI; 3. Guidelines related to weight management in SCI; 4. Identifying challenges (and solutions) to weight management in SCI; 5. Strategies for providers to facilitate weight management; 6. Understanding goals, motivators, and desired feedback for weight management; and 7. Knowing how informal caregivers are affected by weight and weight management of care recipients with SCI. High ratings (>80% strong agreement) were achieved on content, word choice, organization, relevance, and actionability. Modification needs were identified and subsequently made to layout, visual aids, and provision of tangible resources. Providers described the curriculum as a scientifically rigorous resource that addresses a knowledge gap, provides population-specific content, and is useful across interdisciplinary teams.

CONCLUSION

We developed a self-directed learning educational curriculum addressing topics most salient to stakeholders involved in overweight/obesity management of persons with SCI.

Rates, Variability, and Predictors of Screening for Obesity: Are Individuals with Spinal Cord Injury Being Overlooked?

INTRODUCTION

Individuals with spinal cord injury (SCI) are vulnerable to obesity. Annual obesity screening using body mass index (BMI) is the standard of care mandated by US Veterans Health Administration (VHA) guidelines. Our objective was to determine the rates, variability, and predictors of guideline-concordant annual screening for obesity, given potential challenges of height and weight measurements in individuals with SCI.

METHODS

This is a cross-sectional retrospective study using US national VA databases. We identified all VHA patients with chronic SCI in the fiscal year (FY) 2019, their treating facility and frequency of recorded height and weight. We applied mixed-effects logistic regression models to assess associations between annual BMI screening and patient- and facility-level characteristics.

RESULTS

Of 20,978 individuals with chronic SCI in VHA in FY19, guideline-concordant annual BMI screening was lacking in 37.9%. Accounting for facility-level factors (geographic region, SCI facility type, volume of patients with SCI treated at the facility), a mixed-effects logistic regression model demonstrated that lack of annual obesity screening was significantly associated with older patient age (p < 0.001) and fewer outpatient encounters (p < 0.001) but not other patient-level factors such as sex, race, level of injury, or rurality. The rate of obesity screening among different facilities within VHA varied widely from 11.1% to 75.7%.

CONCLUSION

A large proportion of persons with SCI receiving care in VHA do not receive guideline-concordant annual obesity screening, an especially acute problem in some facilities. Older patients with fewer outpatient encounters are more likely to be missed. To inform the design of interventions to improve identification and documentation of obesity, further study is needed to assess potential barriers to obesity screening in the population with SCI.

Strategies used by providers to support individuals with spinal cord injury in weight management: a qualitative study of provider perspectives

STUDY DESIGN

This is a descriptive qualitative study.

OBJECTIVES

To explore recommended strategies employed by healthcare providers to support individuals with SCI in weight management.

SETTING

Fourteen veteran administration hospitals in the United States and the Shirley Ryan AbilityLab (SRALab) SCI Model Systems in Illinois.

METHODS

Semi-structured interviews were conducted with interprofessional SCI providers involved in weight management with individuals living with SCI. Thematic analysis methods were used.

RESULTS

A total of 25 interprofessional providers were interviewed. Providing clinical expertise to assist in weight management included (1) checking progress or status of weight over time, (2) monitoring and tracking other health-related indicators, (3) stressing weight-related health risks, (4) providing education, (5) encouraging healthy behaviors, and (6) identifying and accessing resources. Fostering provider-patient relationships included (1) establishing and maintaining rapport and (2) tailoring/individualizing weight management treatment. Coordinating a team approach included (1) involving a dietitian or nutritionist, (2) communicating the same message, and (3) involving the informal caregiver/family.

CONCLUSION

Weight management strategies should incorporate patient preferences and goals, informed through provider expert and personalized clinical advice, and supported within the context of interprofessional team collaboration that includes caregivers and family.